- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,897.79 / $16,595.87
| Facility | | $2,630.27 | $4,897.79 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $245.47 / $2,691.53
| Professional | | $54.95 | $245.47 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $104.71 / $186.21
| Facility | | $56.23 | $104.71 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,202.26 / $3,548.13
| Facility | | $380.19 | $1,202.26 | $3,548.13 |